I had the most endearing interaction I think I've ever had today with a patient.  He was an extremely polite schizophrenic man who came in because he was convinced his water supply was being poisoned.

Me: What makes you think your water is being poisoned?

Him: Well, my girlfriend, she told me to drink less water.  She thinks I have too much every day,  so she told me to drink less.  I'm pretty sure she poisoned it.

Me: Why would she want to do that?

Him: To get me to drink less, of course.

The logical explanation lies with his past medical history; he suffers from a condition known as potomania - overactive thirst - which can cause significant electrolyte imbalances in the body with too much water ingestion.  The treatment is to drink less water; his girlfriend was actually looking out for him.

For a moment, I entertained the fallacy of his reasoning.  "Why on earth,"  I thought to myself, "would your girlfriend poison your entire water supply? This is the schizo talking."

Then, I thought back a couple of weeks.  In the middle of a particularly hectic shift I took care of an autistic kid who kept coming up to the physician's desk asking the same question over and over again.  "Can I get my medication refill now?  Please, I want my medication refill now.  Now? Now."  I finally lost my temper and snapped, "Listen, kid.  I'll get to it when I have the time.  Right now I have more important things to do than refill your meds."

I saw the hurt in his eyes and immediately regretted my words.  One of our child life specialists who I deeply respect pulled me aside and admonished me.  "Zac.  He's scared, it's loud in the ER and he needs help.  He's autistic and he's already out of his comfort zone.  I know you're busy, but don't lose your compassion."

Fast forward to today.  "Tell you what, boss," I said, "why don't I do a good physical exam and we'll make sure you didn't get water poisoning?"

"That would be great," he said, "I've been so worried."

I've been reading Cutting For Stone by Abraham Verghese, a physician at Stanford well known for his veneration of the physical exam.  Dr. Verghese gave an incredible TED talk about the powerful bond a careful exam creates between physician and patient.

So, finding myself with a few extra minutes in my day, I examined my schizophrenic patient in minute detail.  I tested for nystagmus, checked Romberg and Babinskis, carefully listened for the slightest of cardiac murmurs, and checked his ears for wax.  And, after a normal exam:

"Good news, I don't think your water was poisoned!"

His response was wonderful. "Doctor, thank you so much.  You've put my mind at rest.  It was going round and round like a carousel and I couldn't seem to get off the ride."

I suppose a physician's touch - even in a busy ER - is still a valuable tool.

I've written a novel!

Well, sort of.  It's been a longtime dream of mine to write an actual novel, so I did a bit of investigation.

On a whim, I exported my entire blog to Word. It comes out to exactly 197,748 words in length, excluding comments.  Wikipedia (as you know, this is my favorite source for 100% factually correct links) states that most novels are somewhere between 50,000-175,000 words in length. I figure that makes my blog a novel equivalent!

Incidentally, my last post was post #400.  Thank you, dear readers, for bearing with me for all these years.

You know your blog is sort of popular when publishers start sending you books to review.  Sadly, a lot of the books I've been sent have been... well, poorly written.

Sometimes they lack a distinct narrative.  Sometimes the author just doesn't know how to write.  Sometimes I find myself actively hating the narrator. Worse, I realize they are shitty doctors.  There is a huge gulf between most of the books I get sent and captivating novels like House of God or Complications.

Rather than selling out my physician writer friends (hey, it's not easy to both write and see patients) by writing scathing diatribes on every book I'm sent, I've just chosen not to review crappy books.  Perhaps one of these days something will come along that will so captivate my attention I recommend that you all read it.  For now, I suppose you'll have to put up with my blog.

In the meantime, publishers, keep 'em coming my way. I've got a veritable bookshelf of mediocre medical books.  More fuel for for my eventual masterpiece.  Yes, dear readers, eventually there will be a book by yours truly.  And none of this ghostwritten shit, either.

I'm really enjoying being a senior resident.  This month I'm mentoring our medical students, and it's been loads of fun so far.

Today we had a "simple" laceration that needed closing.  Typically this is the medical student's job, since the residents have traumas and coding patients to take care of.  I sent Medical Student to sew up the lac, but two minutes later he came out of the room, pale-faced and nervous.

"Dr. Zac... I took off this guy's pressure dressing and he's kind of... bleeding out from his wound.  Like, sort of spurting blood. Kind of everywhere. I think I need help."

I'm a pretty laid-back guy, but years of emergency training have instilled a GO switch in me.  I immediately popped in the room.  Sure enough, this guy was hemorrhaging blood from multiple severed arteries in his leg.  I grabbed Med Student's gloved hand and shoved it in the wound.

"You feel where that's pulsing?  I want you to keep your fingers right there and hold pressure.  I'll be right back."

There are varying degrees of emergency; this is one that can be fatal if left unchecked.  I ran out of the room, grabbing the necessary equipment and sutures.  Med Student seemed quite relieved when I returned.  Quickly I tied off the bleeding arteries while explaining what I was doing (throw your stitch under the artery, loop back around again, and tie it off.  This is called a figure-of-eight suture and it will save your ass in a pinch).  Within a minute I had the bleeding stopped.  Med Student appeared impressed.

Suddenly, it was a simple laceration repair again.  I supervised him closing the wound with little teaching points along the way, and to his credit, he did a fantastic job.  It will look great when it heals.

The patient's wife pulled me aside later.  "Doc, you really seem like a fantastic teacher.  We were both so reassured that you were there. Thank you so much for taking such great care of us!"

It was a great day, and it's been a wonderful month so far.  If the rest of my life is like this, I'll be a very happy physician.

Our emergency department just switched over to a new EMR.   The transition has gone quite well - my charting has gotten faster and better overnight, orders are infinitely easier to put in the system, and I have more time to spend with patients.  All in all, I could not be happier.

One thing in particular stands out with sheer awesomeness.  We can make macros. For the less-technically inclined, macros are simply a way of automating something you do often.  For a computer nerd/engineering type like myself... well, I've made some improvements.

All I need to do is pick up the dictaphone and say "Computer, activate command center."  I then walk away and see my first patient.

Within seconds it boots up all of my patient records, EKG-reading software, radiology images, drug databases, and email.  Then it opens up another window and prints out:

"Command center online, Dr. Zac.  Have a wonderful day!"

It's really the greatest thing that's happened to me since... well, ever.

I have my very own HAL-9000!

Being an ER doctor isn't all fun and games.  Well, it's usually fun, and mostly games, but really we're at the mercy of the city and its drunk and dying denizens.  When two trauma 1's roll through the door at the same time, a scattering of chest pains and GI bleeders are still waiting to be seen in the back rooms, and the hallways are filled to the brim with gurneys... well, my heart rate starts to rise.

I enter autopilot, and start doing what I loathe the most - overtesting. It's what emergency physicians refer to as "moving the meat."  It's a term I hate, but when there are multiple patients needing to be seen - any of whom could be dying - and the department is bedlam, it starts to make sense.

Chest pain?  Check.  How long?  Describe it for me.  Risk factors for cardiac disease.  Labs, chest x-ray, pain control, next room.  In and out the door in a couple minutes.  Scribble on the chart, "typical chest pain story, patient appears well and in no acute distress, check labs.  EKG nondiagnostic, will evaluate xray for pathology and admit for observation."

It becomes formulaic at this point.  Patients with abdominal pain get "belly labs" and a CT.  Headaches get compazine/benadryl/decadron and probably a CT & spinal tap.  Traumas get "trauma labs" and a $15,000 full body CT scan to search for any hint of bleeding - it exposes them to approximately half the radiation experienced by survivors of Hiroshima.

My normally friendly bedside manner goes out the window.  I'll usually introduce myself, "Hi, I'm Doctor Zac and I apologize for being brief.  Unfortunately an SUV just overturned on the highway and they'll be arriving in 5 minutes, so I just wanted to pop in and see how you were doing."

I never yell, but I can be brusque.  Before residency, I would have never imagined myself to be the type to say "I'm sorry, I don't have time for you right now,"  but it happens.  At least I always say "I'm sorry" first.

I suppose it's part of being a feast-or-famine specialty.  We don't have the luxury of scheduling our patients.  It still leaves an unpleasant taste in my mouth when I don't feel like I can care for people the way they need to be cared for.  Especially when it means spending thousands of dollars of their money that I know they don't have, and delivering enough radiation to possibly cause cancer down the road.

I saw a cardiac patient today; 3 stents, COPD, peripheral vascular disease... the whole 9 yards. While asking him my standard social history questions (smoke, drink, do any street drugs?) he hung his head low.

"Yeah, my doc tells me I gotta quit, but I can't get down to less than a pack a day."

It's something I hear all the time. I've talked to smokers who are crack and heroin addicts - they say that the nicotine urge is worse than any other addiction they've fought.

For better or for worse, patients seem to focus on the lung cancer aspect of smoking. I suspect it's due to a particularly effective ad campaign in the past few decades, but the truth is, smoking is far worse with regards to other diseases. Tobacco, whether chewed, smoked, or snu'ed causes a huge variety of vascular diseases.

I figure it should be easy enough to calculate the cost of a pack of cigarettes. Ask a random sampling of ER patients how much they smoke per day (we measure tobacco use in pack-years, i.e. the number of packs per day they've smoked times the number of years). Get permission to access their healthcare records, and calculate the differential in healthcare costs between smokers and non-smokers.

Take that differential, divide it by pack, and add it as a healthcare tax.  I support people's right to make bad choices; I also support their right to pay for those choices.

Your thoughts?

So in the process of converting my site over to a new look (and we're still not done, new theme on it's way!) I seem to have lost my blogroll. If you're someone I've linked to in the past, drop me a comment here and I'll be happy to add you to my blogroll. New readers, that goes for you too!

As always, feel free to give me feedback at agraphia.mailbag@gmail.com

While talking to a very amicable, pleasant schizophrenic man today:

Him: The voices in my head, they tell me all sorts of things.

Me: Like what?

Him: Don't eat raw bacon.

Me:  ... smart voices!

Lady, it's 4:17AM. Why are you bringing your child in for a "fever" of 99.2 degrees without any symptoms whatsoever? "Just to get him checked out" is not a good enough explanation.

Here are some possible reasons I came up with:

1. Me and my boyfriend were up partying all night with blow and ecstasy and we decided to keep the party going all up in this hospital.
2. I work at 5:30AM and this is the only time I could find to bring my kid in.
3. The kids were up partying all night with ketamine and poppers, so I figured I'd get them checked out since they were still awake.
4. We set our clocks ahead by three hours at my house so we're never late for anything.
5. Something is horribly wrong with my child and I noticed it when he woke up from sleep at 4AM.

Since you've made it clear that #5 is not the answer, I guess I'll go with #1.  Also, ma'am, contrary to what you may think, being seen in the ER is not free. Giving our registration people a fake phone number isn't going to get you out of paying the bill.